Category: Surgery

I have not written for a while because so much of my time out of work is spent on appealing denial of payments by Novitas, the Medicare administrator for Texas. They have denied care for patients who have had treatments that are considered as class 1 evidence for management by all the major vascular societies, including the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation, and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). In 25 years of doing this work, I have never encountered such nonsense. I thought I was the only one going through this trouble. Then I find out that a cardiology colleague of mine in South Dallas has the same issue. By word of mouth, I talked to a cardiologist in Illinois who just went through the same problem. I bet there are more physicians that are being inappropriately denied payment for standard of care by Novitas. Nothing against the profession, but I found out my cases were reviewed initially by a licensed vocational nurse (LVN). Hell, even many physicians don’t fully understand what we do and why. To add fuel to the fire, apparently Novitas keeps 12% of the amount of money that they recoup from physicians such as myself as a bounty. When I reviewed a case with one of the Novitas nurses early in the course of this appeal, she told me “Well you know sometimes people need to have an amputation of their leg rather than an attempt at limb salvage.” THERE IS SOMETHING GOING ON HERE, AND I WOULD LOVE TO HEAR FROM OTHER PHYSICIANS, BILLING PEOPLE, AND HEALTHCARE PROVIDERS ABOUT THEIR PROBLEMS WITH NOVITAS OR ANOTHER MEDICARE ADMINISTRATOR.

Someone asked me to wrote more about carotid artery disease, so here goes. We see a large number of patients with carotid artery stenosis. Next to aneurysms, I don’t think that there is any other medical condition that raises more anxious feelings for patients. The paired carotid arteries supply the left and right side of the brain. There are ale smaller arteries that supply the back of the brain named the vertebral arteries, and there is a communication between the 2 systems within the brain called the Circle of Willis. But the dominant supply to each side of the brain is via the carotid artery. Blockages in the carotid artery can lead to strokes. The typical symptom of a stroke are loss of motor control on one side of the body versus the other, loss of speech ability, and loss of vision in one eye versus the other. Stroke symptoms do not cause pain, and vague symptoms such as dizziness and vertigo are not typical of strokes (unless it occurs in a certain area of the brain that control balance).

The typical risk factors for carotid artery disease are the same as for other cardiovascular diseases, namely cigarette smoking, high blood pressure, high blood sugar, high cholesterol, age and family history. Age and family history you are stuck with. If Dad or Mom had heart disease and strokes at an early age, then unfortunately you are probably at a higher risk. But the other risk factors are able to be controlled with medication if needed, or diet and exercise and smoking cession.

Most people with carotid artery disease never have symptoms. In general, the higher the degree of narrowing, the greater the risk of symptoms. Sometimes, you can have what is called a Transient Ischemic Attack (TIA) or mini-stroke, and at other times you might have a full blown stroke. The difference between the two is that a TIA resolves within 24 hours, while a stroke last greater than 24 hours. We don’t know which event is going to occur, if it does occur. We just know if you have a TIA, and you have significant carotid artery narrowing, your risk for a full blown stroke is a lot higher.

Most patients with carotid artery stenosis do not need surgery. We emphasize controlling the risk factors, as well as smoking cessation. I advocate an anti-platelet agent such as Plavix or aspirin, and close follow-up. We used to be much more aggressive with carotid stenosis in terms of surgical management years ago. However, in the era of anti-platelet agents such as Plavix, as well as statin drugs to control cholesterol level, and much better management of diabetic patients by our family practice and medical colleagues, the role for carotid artery intervention has diminished. The options for management of carotid stenosis include carotid surgery where the blockage is cleaned out versus carotid artery stenting where the blockage is essentially reopened with a stent. There is an ongoing debate about which technique is better for patients. I suspect the answer is going to be dependent on the patients age, and anatomy, as well as other cardiovascular issues such as heart disease.

I dont think there is any doubt that if you have a TIA or a stroke with good recovery, and you have severe carotid artery narrowing on the side of the stroke, that you would benefit from carotid artery intervention to reduce further strokes. What is less settled to me in the modern era is what should be done for patients with moderate to severe carotid artery disease (greater than 60% narrowing) who do not have symptoms of TIA’s or strokes. There are carotid stents or carotid surgeries being performed for that condition (so called asymptomatic carotid stenosis), but the data is not clear in my mind of the benefits of the intervention versus the risks. Thats what this whole business is about, balancing the risks versus benefits of every intervention we do.

The carotid arteries are the main blood supply to most of the brain. The right carotid artery supplies the right side of the brain. A right sided stroke symptom will include loss of vision in the right eye, kid of like those old movie theaters where a curtain comes down over part of the eye or all of it. This event is called Amaurosis Fugax. Another potential symptom of a right brain stroke is loss of motor control of the left side of your body. You may be stirring a cup of coffee with your left hand, and all of a sudden you can lift your hand. There is no pain associated with these events. A left brain stroke will cause the opposite event to the right side, namely amaurosis fugax of the left eye and loss of right sided motor control. In addition, most peoples speech centers are on the left side of the brain, so you may lose your ability to speak even though you know what you want to say, or it may come out as a string of non-sense words.

Carotid artery blockages are one of the many potential reasons for a stroke. The risk factors for carotid artery disease are the same as the risk factors for other cardiovascular diseases. These include 1. Cigarette smoking

2. Diabetes

3. High blood pressure

4. High cholesterol or triglycerides

5. Age

6. Family history of circulation problems

Most people with carotid artery narrowing do not know they have it. If you have had a heart attack or has peripheral vascular disease, then you have a higher risk for carotid artery narrowing. Most patients with carotid artery stenosis do not need surgery. Age and family history you are stuck with! Our goal is to prevent the narrowing becoming worse but making sure that your blood pressure, blood sugars, and cholesterol levels are well controlled, and that you stop smoking.

If you have been diagnosed as having carotid artery narrowing, the prognosis is really quite good. Most people will never need their carotid artery repaired. Th old standard for treatment of carotid artery narrowing that was 60% or greater was surgical intervention based on a study published in the New England Journal of Medicine. However, this study was prior to the current era where we have Plavix which is like a super aspirin, and statin drugs. Therefore, the management of carotid artery disease has changed somewhat to a more conservative approach, as outlined by the writings of Dr. Frank Veith, one of the most thoughtful and smart vascular surgeons who has been around a long time and seen it all. I personally discuss surgery in patients who have had a TIA or ministroke and carotid artery narrowing on the side of the TIA. A TIA is a stroke like symptom, but by definition, you recover function within 24 hours. If you have a TIA, and have severe carotid artery narrowing on the side that caused the TIA, then you have a high risk for a full blown stroke, and really should have intervention for the carotid artery narrowing.

In terms of treatment for carotid artery stenosis, as I mentioned most people do not need intervention, and can be managed with anti-platelet agents that thin out the blood such as aspirin or Plavix, as well as control of their cardiovascular risk factors, statin drugs as necessary, and smoking cessation. Why not fix all carotid artery narrowing when it’s present? Because the intervention itself carries a risk for stroke and even heart problems. This business is all about balancing the risks versus benefits of everything we do. If the risk of stroke is low with carotid artery narrowing, then it is better managed conservatively. If intervention is required, the options are to either have a surgical intervention or a carotid artery stent. There are advantages and disadvantages of both. I personally do not do carotid artery stenting; I think that is better left to someone who has experience in doing the procedure, but also in fixing problems that may arise both during and after the procedure. If I think a patient is better served by a carotid artery stent rather than surgery, I will ask them to see a friend of mine who is a neurointerventional radiologist, basically a specialist in all things related to the blood flow to the brain. He might come back and tell me “no, I think this case would be better served by surgery, or yes I think carotid artery stenting would be a good option.” Remember the old adage “if your only tool is a hammer, the whole world looks like a nail.”